Aims: This paper reports a study describing community Nurses' health promotion work with older people aged 50 years and above, and exploring particular health promotion initiatives for older people that would have transferability potential.
Background: With the ageing of populations worldwide, community nurses in primary healthcare settings have a key contribution to make to the health improvement agenda for older people, yet little is known of the extent of this aspect of their work.
Methods: Questionnaires were sent to 1062 community nurses in six Scottish National Health Service Boards – public health nurses/health visitors, district nurses, general practice nurses, community psychiatric and learning disability nurses and combined duty nurses; 373 (35%) responded, 30 of whom were interviewed by telephone. The data were collected in 2003–2004.
Findings: Findings confirmed the wide scope of health promotion, much of which may be embedded and unrecognized. Creative group work showed promise in achieving heath gain for older people, and a range of partnership approaches – interdisciplinary, multidisciplinary and interagency – was evident. Theoretical input and project opportunities within educational programmes had been a catalyst for health promotion initiatives in practice. However, evidence of audit, evaluation, and active involvement of older people in planning health promotion was limited. Funding of health promotion initiatives was vital to sustainability.
Conclusion: There is merit in making the health promotion work of community nurses more visible through audit and systematic evaluation; promoting the active involvement of older people; strengthening partnership working; and further raising the profile of health in later life within undergraduate and postgraduate community nursing programmes.
The promotion of healthy ageing is an international imperative for policymakers and practitioners [World Health Organization (WHO) 2004a, 2005]. The need to ensure an enabling and preventative approach to the care of older people raises important issues for nurses who work in primary care and community settings. In this paper, we give new insights into the nature and limits of the contribution of community nurses, focusing specifically on their health promotion work with older people.
Health improvement and healthcare for older people are priorities in global and national policy agendas (Scottish Executive 2000, 2001a, Department of Health 2001a, WHO 2004b). With the ageing of populations in both developed and developing countries, the WHO (2005) has called for policy reorientation towards integrated health and social systems serving older populations, and for initiatives to strengthen active and healthy ageing.
Policymakers recommend that demographic change should be viewed not as a problem, but as an opportunity to focus on promoting health positively in later years (Wood & Bain 2001, WHO 2005). However, in health promotion policy and practice, there are tensions between the traditional biomedical orientations towards disease prevention and the current drive towards maintenance of positive health and well-being amongst both older people who are fit and those with chronic disease. Downie et al. (1996) note that, although preventive and positive health promotion objectives tend to be combined, it is the positive health dimension that is too easily lost in practice.
The health of older people is an area of concern in research agendas worldwide (Victor & Howse 2000, Gattuso 2003, Lai et al. 2004, Mokdad et al. 2004). In the United Kingdom (UK), evidence of the effectiveness of health promotion interventions in improving and maintaining older people's health is appearing (Cattan 2001, Elkan & Kendrick 2004). For example, a survey by Sourtzi et al. (1996) showed health promotion to be a significant part of community nursing roles; however, it gave no details of community Nurses' health promotion work with older clients.
Problems for health promotion have been noted (Squire 2002) where community Nurses' attitudes remain ageist, and where old age is associated with dependency and disability rather than with potential for health gain. It has been suggested that nurses limit the scope of their work by adopting a biomedical, behaviour-change approach, rather than negotiated empowerment-orientated, community development or socio-political approaches (Latter 1998), and a need for audit and effective evaluation of health promotion practice has been identified (Clark 2001, Whitehead & Russell 2003, Whitehead 2003).
Overall, there is considerable uncertainty in the UK about health promotion practice with older age groups, and health promotion in ageing is still relatively neglected and poorly understood (Cattan 2001). No national survey of health promotion work with older people had been conducted in Scotland prior to the study reported here.
Like other UK countries Scotland, with a population of 5·1 million, is experiencing growth of its older sector (SCROL 2004). Currently, people aged 50 years and over represent 33·7% of Scotland's population. Between 2002 and 2031, the number of people above 65 years is expected to increase from 0·8 to 1·2 million and those above 85 from 88,000 to 151,000.
The 15 Scottish National Health Services (NHS) Boards oversee local healthcare provision and a variety of health-related partnerships with local government and the voluntary sector (Wimbush et al. 2004). Within each NHS Board area to 2004 Local Health Care Co-operatives (LHCC), which incorporated a number of GP practices and health centres, were responsible for conducting locality health needs assessment and primary care service planning. They encouraged innovation in health improvement through new partnerships between community nurses and colleagues in primary care teams, social services and the voluntary sector (Scottish Executive 2001b, 2003a). LHCCs are now being aligned with local government authority services and redesignated as Community Health Partnerships (Scottish Executive 2004).
Coronary heart disease, stroke, cancer and mental health problems are target areas for health improvement for older people; specifically listed for attention are exercise and physical activity, access to information about healthy lifestyles, tobacco and alcohol use, nutrition, oral health, medication review, foot care, falls and fracture prevention, and vaccination against influenza (National Osteoporosis Society 2000, Scottish Executive 2001c). There is also a commitment to empowerment of older people and partnership with them in the planning, delivery and evaluation of primary healthcare (Scottish Consumer Council 1999, Scottish Executive 2001d).
Ability to interpret the concept of healthy and active ageing and to engage in health promotion is an expected part of the work of community nurses in the UK (Squire 2002). In the study reported here, the health promotion work of six groups of community nurses was considered – public health nurses/health visitors (HV), district nurses (DN), general practice nurses (PN), community psychiatric nurses (CPN), community learning disability nurses (CLDN) and combined duty nurses (COM), the latter being those in rural areas who might, for example, have midwifery and district nursing and/or health visiting responsibilities. HVs, regarded as experts in health promotion, have traditionally focused on child and family health, with an emphasis on primary prevention. Small and reducing proportions of HV work are with older people, the largest decline occurring in the 65–74 age group (Clark 2001, ISD 2002, Davidson & Machin 2003). However, the HV role is currently in transition, being strengthened in public health, and emphasising community development and targeting health inequalities. DNs and PNs provide clinical nursing and screening for chronic disease management. The highest DN home visiting rate occurs in the 75+ age group, more than one-third of whom are visited in Scotland by a DN. PNs, whose number has doubled in Scotland since 1990, meet older people mainly in GP settings (ISD 2002). CPNs and CLDNs work in mental health and learning disability teams and contribute specialist knowledge to the primary care team. Health promotion challenges for CLDNs are increasing steadily as their client population ages (Barr 2001). All six groups have the potential to make a major contribution to the ‘adding life to years’ dimension of the NHS health promotion agenda (Scottish Executive 2001a, 2001e), but as yet relatively little is known about this aspect of their work.
The study had two aims: first, to survey community Nurses' health promotion work with people aged 50 years and above and, second, to identify health promotion initiatives undertaken with this group that would have transferability potential.
Health promotion was defined as activities with the aims of disease prevention, health education and health protection, and as encompassing activities that enhance positive health, enabling or empowering older people to achieve their full potential (Downie et al. 1996).
A questionnaire survey, with follow-up telephone interviews with a sub-sample, was conducted in 2003–2004 with a stratified sample of community nurses.
From six of Scotland's 15 NHS Boards, a 50% stratified random sample of six groups of caseload-holding community nurses (n = 1062) who worked with older people was drawn: HVs (n = 273), DNs (n = 250), PNs (n = 319), CPNs (n = 151), CLDNs (n = 37) and Combined Duty Nurses (n = 32).
A draft questionnaire was prepared in consultation with Registered Community Nurses, community nurse educators and the ‘Health in Later Life’ team at NHS Health Scotland. Twenty-four older people, accessed at home and at a day centre, were invited to comment and suggest amendments. They refined the wording and recommended seven additions to the list of health promotion topics: help with finance, housework, gardening, personal care, shopping, and securing aids/equipment and personal alarm systems.
Questionnaire reliability was tested with 100 community nursing degree students, each of whom received the questionnaire for completion on two occasions with an interval of four weeks. Test–retest response rates to first and second mailings, with one reminder, were respectively 39% and 32%. Cohen's Kappa values were calculated using SPSS v10 for 155 variables (Altman 2001). Of these, 50% (78 items) achieved very good/good levels of agreement (values: 0·61–0·9); a further 36% (57 items) achieved a moderate level (0·4–0·6). The remaining 20 items, which had low levels of agreement, were deleted or modified.
The questionnaire addressed the following:
Questionnaire respondents who gave information about audit, evaluation, older people's involvement, successful outcomes, an initiative or innovation, were invited to opt in to telephone interviews. Of 113 respondents who were eligible for interview, 45 gave written consent and a telephone number for contact. Of these, 30 who gave sufficiently clear information were selected for interview by the advisory panel: seven HVs, eight DNs, five PNs, seven CPNs, two CLDNs and one Combined Duty Nurse. Interview questions were then identified by the advisory panel and the research team.
As a relatively low questionnaire response rate was predicted from the pilot study, and as it is known that written responses to survey questions tend to be brief, the telephone interview method was selected and designed to elicit more detailed information from respondents. The audio-recorded discussions, which lasted from 15 to 45 minutes, successfully elicited rich qualitative data related in particular to the study's second aim, and to identifying health promotion initiatives that would have transferability potential.
Approval was obtained from the Multicentre Research Ethics Committee for Scotland. To protect anonymity, questionnaires and an explanatory letter, consent form, information sheet and reply-paid envelope were addressed and forwarded to study participants by administrative personnel in the six NHS Boards.
Questionnaire data were coded and entered to SPSS v 11.5 (SPSS Inc., Chicago, IL, USA). A two-stage content analysis of interview transcripts was undertaken to enhance rigour. First, the project researcher extracted themes or issues. Secondly, a random sample of 15 transcripts (59%) was independently analysed by the three grantholders. Following discussion, a high level of agreement in interpretations of data was evident.
From 1062 questionnaires distributed, 373 responses were received (response rate 35%). Of these, 321 (86%) were complete; 58 (15·5%) respondents indicated that they did not undertake any type of health promotion (HP) work with older people, more than half of these being HVs (Table 1). Given this relatively low response rate, caution is necessary in generalising from the survey findings. Whether the response reflects lack of involvement in HP work with older people amongst the non-respondents is not clear, but may have been a key factor.
Table 1 Survey response by community nurse group
The emphasis was on opportunistic HP work, screening/assessment programmes and HP with older people at home (Table 2). The range of ‘other’ community settings in which HP was reported included shops, post offices, community centres, care homes, sheltered housing, day centres, churches, clubs and cafes. A contribution to policy development was also reported.
Table 2 Types of health promotion work reported: survey % response
Although all topics generated responses, only 16 of the 51 topics were ‘actively addressed’ by 50% or more of the sample (Table 3). Less than 50% actively addressed national priorities such as smoking, alcohol, falls prevention and topics related to mental health, e.g. isolation, loneliness, anxiety and stress, memory, dementia, sleep, relaxation (Table 4). Less than 30% of respondents actively addressed osteoporosis and well-being-related topics such as adapting to life changes, personal relationships, travel health, sexual health, positive ageing, driving, working, volunteering, retirement and learning in later life (Table 5). Certain downward trends in percentage response with age, e.g. smoking, alcohol, anxiety and stress and sexual health, were noteworthy.
Table 4 Health promotion topics reported as actively addressed by 30–49% of the sample by age category
Table 3 Health promotion topics reported as actively addressed by 50% or more of the sample by age category
Table 5 Health promotion topics reported as actively addressed by <30%>
Over 70% of respondents identified traditionally dominant HP approaches, focussing on education and information-giving, modifying lifestyle and preventing illness (Table 6). Indicators of an empowering approach were identified by 50% or more respondents – collaborating in decisions, strengthening esteem/confidence, negotiating goals/plans, exploring health beliefs/attitudes. There was a reported emphasis (77·6%) on discussing positive health, well-being and fitness in ageing. However, under 50% reported establishing how older people viewed their health and ageing, or evaluating with the older person the outcomes of health promotion. Lowest percentage responses were found for health inequality, community education, environmental and socio-political approaches.
Table 6 Health promotion approaches reported: survey % response
The main perceived constraints to health promotion work with older people were other work taking priority and lack of time.
Of 39 initiatives identified in the interviews, 18 related to work with individual older people, 18 to groups and three to day-events (Table 7). Further information about these initiatives has been reported elsewhere (Watson et al. 2004).
Table 7 Health promotion with older people – examples of community Nurses' reported initiatives
Only 37 (14%) survey respondents had audited and 28 (10·6%) had evaluated their HP work. In most cases, audit or evaluation was linked to a particular initiative or innovation.
Eighty-four (31·9%) survey respondents claimed evidence of successful outcomes. However, when these were explored at interview, specific outcome criteria had been identified for few activities. Evidence of success was acquired through the use of published and on-line validated packages and rating scales, funders' monitoring instruments, focus groups, questionnaires, case review and oral feedback from older people. Evaluation or audit criteria included group attendance/discharge rates, weight loss, smoking cessation rates, vaccination rates, healing/recurrence rates, improvements in well-being/mood, increase in exercise, gains in confidence, and improved diet. The following is an example of a successful outcome:
A gentleman in his middle 50s…met me in the supermarket one day and he said, ‘I've got some sores on my legs’…his legs were dreadfully swollen and he had just the start of leg ulcers…He was very, very overweight. We started off doing dressings, then got him along to see the vascular nurse. We got his legs healed up and I really encouraged him to go along to (a slimming group)…Up until then he was doing virtually no exercise at all and he has lost two stone by going along to that class and walking around the village every day…I think he's doing 8 miles a day and he just looks a different man. (DN1011)
Evaluation was a higher priority if linked to a requirement by funders or employers for a report, or to the need for extra resources. Published packages with validated tools tended to be used in top-down health board initiatives. Individual nurses or teams had sought help with audit and evaluation from local clinical effectiveness teams, health promotion departments or LHCCs. An interagency approach to evaluation was adopted for health fairs, that is, community events at which representatives of health, social and voluntary organizations give information and advice.
Several participants reported that undergraduate and postgraduate education had been a positive stimulus for initiatives and for engaging in audit or evaluation. However, most respondents reported being too busy to evaluate, and some felt that they lacked evaluation skills. Where audit/evaluation reports had been prepared, community nurses might not have received them or, if they had received them, they might not yet have read them:
Over the 12 weeks of the pilot, we had notes on every group (for older people with functional mental health problems)…But to be honest, it's never been pulled together…We don't have to do it (audit) if we want to continue as we are doing just now, because we've not used any extra resources. But if we want to extend it, if we want some extras, we would definitely have to do it. But it's just a time thing, it's something that's not high in the priority. (CPN 59)
One of the difficulties with evaluation was the relative invisibility and embeddedness of health promotion within daily work:
It's just part of the job – you cannot isolate it on its own. It just goes hand in glove with whatever you do. (PN 86)
There was concern to make evident the ‘invisible’ element and to recognize and record effective HP work where it existed:
Health promotion is an everyday part of my role. It often goes unacknowledged. It is ad hoc in nature for the most part, and therefore difficult to evaluate. This saddens me. If we were able to demonstrate the value and benefits of the on-going health promotion work, perhaps more time and resource would be identified. (DN 208)
Only 49 (18·6%) survey respondents reported on older people's involvement in planning and 37 (14·1%) in evaluating health promotion. However, some form of involvement was evident in the majority of initiatives described at interview. Some groups were initiated and run by older people themselves, and involvement was more passive in professionally led groups. However, where groups were professionally led, community nurses were sensitive to issues of control. There was evidence of consulting older people and attempting to balance policy priorities with their concerns and agendas. Consultation about activities, speakers and health-related topics was common:
One of my colleagues developed this older person's well-being group, which I'm involved in…Local older people come together and decide what they want…They wanted a walking group and so we've established that at a local level…When the winter was coming in we said to them, ‘Right, what other kind of things would you like?’…And they came up with things like oral health. (DN 532)
Two positive outcomes were of interest. There were comments about the Nurses' intention to withdraw once groups were established, in the hope that they would become self-sufficient, and there was evidence that this had occurred:
The idea came from the patients themselves…It's more a kind of informal ‘they know I'm here’ support kind of role that I have…Once it was established, we had the idea that the professionals would back off and let the group run itself…Once they realized that they had the power, it was lovely to watch people just take it and run with it. (CPN 64)
Social gains from group membership were also regarded as a major benefit of group work, and it was not uncommon for groups to have a primary purpose, but primary and secondary benefits:
The initial 8 weeks was paid for by health promotion, and then the ladies were so keen to carry on with the exercises that the group is actually still running…The oldest is 84…I've been amazed at the improvement in fitness…It has been wonderful to see the benefits of this programme, socially as well…They're more likely to get together to go out for a walk at other times, and it has a knock-on effect. (DN17)
In some health centres, patient participation groups had been set up. Where they were proactive, groups sought action not only for their own concerns as older people, but also lobbied on behalf of community nurses for action on professional issues:
Our patient participation group is really quite elderly…Our one is very proactive. They're looking to become a charity and (find) funding for things like a prescription delivery (service)…They've done ‘No Smoking’ surveys…They feed into our primary care team meetings – we wanted to meet the doctors regularly and bring forward our concerns, and they're actually very good: they will lobby the (NHS) trust for us…They have a good voice and they're not frightened to use it. (HV 962)
Collaboration in some form was evident in almost all initiatives, and there were examples of successful partnership working:
…from the Scottish Community Diet Fund…we got nearly £3000 (US$ 5245, [Euro sign]4394) to have a subsidy on the fruit in the local shop. It was…me and the dietician and the health visitor and the local councillor and it was really partnership working at its best. (COM 77)
Overlap of health promotion interests between PNs, DNs and HVs, with co-working arrangements, was noted. For example, in the context of new GP contract arrangements and discontinuation of health screening of people above 75 years of age, PNs talked of needing to devise, with colleagues, new ways of ensuring contact with this potentially vulnerable group, particularly those who were housebound. For HVs, the paradox of their health promotion expertise but relative marginalisation of work with older people was evident; partnership working may represent a key opportunity for capitalizing on their expertise.
Problems of definitions, terminology and lack of shared understanding hampered health promotion work with older people:
If you mention health promotion to a social worker, the words themselves don't sit very well…They would rather think about quality of life, but they address the same issues…They call it health improvement rather than health promotion. (CPN 171)
CPNs were also aware of tenuous links between community mental health teams and primary care teams:
We're dealing with people with serious mental health problems like schizophrenia or manic depressive psychosis. They don't engage as easily into, say, the health visitor's smoking cessation group…There's not many of them we can get along to Weightwatchers and Scottish Slimmers, which is what the general public would use. (CPN 158)
CLDNs drew attention to the inappropriateness, for older people with learning disability, of ‘mainstream’ primary care health promotion, and to the need for ‘tailored’ preventive services, e.g. for cervical screening and mammography:
We'll be trying to give practice nurses the competence and the skills to be able to do more with people with learning disabilities…breast screening, cervical screening – that kind of thing very often is forgotten about…Very often problems maybe aren't picked up on…they're not accessing the GP and practice nurses as much as other people would. (CLDN 48)
Funding was reported as the key issue in sustainability and the transferability potential of the initiatives described. Funding sources included the Scottish Executive, Lottery Fund, Health Boards, LHCCs, GPs, local government authorities, endowments and voluntary organizations. Initiatives were vulnerable because of one-off time-limited funding, and considerable creative energy was expended in chasing funds. It was felt that the requirement to account formally for use of funds, through audit and reports, increased the likelihood of continued financial support. On the positive side, the availability of free on-line resource materials for health promotion was valued.
The data confirm the considerable scope for health promotion work with older people. Respondents claimed to address the range of topics with emphasis on policy priority areas related to heart health, diet, exercise and vaccination programmes. The range of health promotion possibilities represents, however, dilemmas for choice and focus. Prioritization of effort needs to be kept under review because key topics with potential for health maintenance and health gain, for example, those related to mental health and positive ageing, were less frequently reported and may merit greater attention. Mental health is known to be fundamental to well-being in later life, and links between positive mental health and good physical health are well-recognized by both clinicians and policymakers (Department of Health 2001a, 2001b, Scottish Executive 2003b, Heikkinen 2005). As the population ages, community nurses will need to respond to the fact that more older people will be at risk from poor general health, disability, dementia, alcohol misuse, low income, fear of crime and social isolation, all of which influence mental health and well-being.
Comments about health promotion's embeddedness within community nursing point to a need to make it more obvious through, for example, audit and evaluation. Perceived lack of skill for such activities should be addressed. It is well-recognized that the expertise of experienced nurses rests on a complex blend of skills and knowledge-in-action; acquiring evidence of outcomes of health promotion work with older people is a potentially fruitful area for research.
It is widely recommended that older people should be fully consulted and involved in planning for health and social services (Help the Aged and Health for Older People 2000, Beth Johnson Foundation 2003). Our findings suggest that there is as yet little evidence of this in relation to health promotion.
Effective health promotion intervention requires understanding of older people's perspectives and acknowledgement of the fact that these may differ from those of healthcare professionals (Bryant et al. 2001, Duaso & Cheung 2002). It has been shown, for example, that professionals tend to consider social isolation, loneliness and aloneness as interchangeable, whereas older people do not (Cattan 2002). This was confirmed during the questionnaire design phase of this study, where older people advised us to record social isolation and loneliness as two items, rather than one.
Awareness was shown in our data of the value of the social element in group activities. Previous work has shown that many older people are unlikely, for example, to participate in exercise for its own sake or for health reasons, and that attempts to promote activity should stress the social rewards (Stead et al. 1997, Andrews 2001). Achieving effective engagement of older people in evaluation-related activities is known to be challenging, and involvement processes need to be more than tokenistic (Alborz et al. 2002).
In terms of the approach to health promotion work with older people, biomedical, preventive and opportunistic work mainly with individual older people was common; however, there was also evidence of incorporating empowerment principles. Although the survey results overall suggested little group or community development work, it was of interest that at interview 15 of the 30 community nurses described group-related initiatives, some of which were highly creative, involved partnership-working and showed promise for physical, mental and social health gain.
It has been suggested that the practice of health promotion has tended to neglect people with ill-health (Buetow & Kerse 2001). The PNs interviewed claimed strongly that health promotion was a key part of chronic disease management, and that people of all ages were ‘treated the same’. While this inclusive and non-discriminatory approach is encouraging, there is the risk that it might fail to take account of evidence about the particular health promotion perspectives and needs of older age groups.
It has been suggested that the demands of audit, performance measurement and the pace of change may place a strain on partnership processes (Charlesworth 2001). However, an interesting range of interprofessional and interagency collaborative partnerships in health promotion, initiated by individual community nurses or primary care teams, or designed at LHCC or Health Board level, were described. Supportive nursing leadership at LHCC level, close to practising community nurses, appeared to be influential. Partnership working emerged as a strategic response to policy, and as a pragmatic response on the part of community nurses to sharing the load and getting the work done.
There was some evidence of PNs, HVs and DNs capitalising collaboratively on their respective health promotion skills and perspectives. However, the telephone interviews confirmed the need for closer partnership between primary care colleagues and community psychiatric and community learning disability nurses in developing health promotion services specifically tailored to the needs of older people with mental health problems or with learning disability (Barr 2001, Powrie 2003).
Texts devoted to health promotion and older people now exist (Killoran et al. 1997, Bernard 2000, Chiva & Stears 2001, Squire 2002). These present useful frameworks for health promotion practice, challenging negative mindsets about ageing and acknowledging potential for health gain in both fit older people and those with pre-existing health problems. Whether, and how, community nurse education programmes in Scotland are addressing health in ageing and health promotion with older people is not yet clear and is currently being investigated. From our telephone interviews, it seemed that theoretical input and project opportunities within educational programmes had been the catalyst for health promotion initiatives with older people. However, when asked to identify in the questionnaire whether their health promotion initiative was linked to a particular theory, for example self-efficacy theory, or to a particular strategy, for example minimal intervention, only 23 community nurses of the 37 reporting initiatives were able to do so. There is scope for further exploration of the theoretical underpinnings of community Nurses' health promotion work.
Involvement of older people, practitioners and experts in questionnaire design enhanced the validity of the data collection instrument. It may, however, require modification to ensure its sensitivity to local issues in other settings. The questionnaire was designed specifically to give an opportunity for respondents to opt into the telephone interviews, during which their work was explored in greater detail than is afforded by postal survey. This mixed-method approach was successful in eliciting both breadth and depth of data. As a consequence of the low questionnaire response rate, however, we cannot claim to have captured a full picture of community Nurses' health promotion work with older people. We also acknowledge that self-report data do not necessarily reflect actual practice.
Our findings raise issues for policy, practice, education, joint service working and further research, and the project report (Watson et al. 2004) offers tools for replication of the study. WHO (2004b, 2005), in relation to their ‘Active Ageing’ and ‘Towards Age-Friendly Primary Health Care’ initiatives, note the importance of health promotion in optimizing opportunities for health, participation and security. In this Scottish study, there was some evidence of health promotion work supporting these three pillars of WHO's (2005) conceptual approach to active ageing for those aged 50 years or more.
Overall, our findings suggest that there may be merit in the following:
A particular challenge lies in partnership work with older people to explore their understandings of health in ageing and to interpret health promotion both as a catalyst for positive health gain and as a support in the context of health deficits and difficulties in later years.
The research team gratefully acknowledges the help received from the participating community nurses, NHS Boards and the advisory panel which included a group of older people. The study was funded through a Scottish Executive Health Department Chief Scientist Office (CSO) grant. The views expressed here are those of the research team and not necessarily those of the CSO as the research commissioners.
PR, HW, JM and DT were responsible for the study conception and design and drafting of the manuscript. PR, HW, JM and DT performed the data collection and data analysis. HW obtained funding. PR, HW, JM and DT made critical revisions to the paper. HW, JM and DT supervised the study.
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Keywords: community nursing; empirical research report; health promotion; older people; questionnaire; survey; telephone interview
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Version: OvidSP_UI01.01.00, SourceID 34
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